The False Claims Act 

(31 U.S.C., Chp. 37)

This statute is used to prosecute, civilly, those professionals in occupational therapy offices who purposefully submit fraudulent or false claims to insurance companies in order to receive a payment.

For example, if an home health care service bills a patient’s insurance company for home nursing services that were never actually provided to that patient, that service may be charged with fraud under the False Claims Act. 

If you are found guilty of a violation of the False Claims Act, you could face a fine of between $5,000 to $10,000. 

In addition, you can be ordered to pay up to 3 times the amount that the government was defrauded of as a result of the scheme. 

The Anti-Kickback Statute 

(42 U.S.C. § 1320a-7b(b))

This statute looks to punish the purposeful  payment made in order to reward people or companies for patient referrals or the generation of business involving any item or service payable by the federal health care programs, including Medicare and Medicaid. 

For example, if an oncologist pays a dermatologist to refer, specifically, patients with Medicare to come to the surgeon’s office. This would be a violation of the Anti-Kickback Statute.   

If you are found guilty of violating the Anti-Kickback statute you face fines of up to $25,000, a prison sentence of up to 5 years, or a combination of both.

The Physician Self-Referral law (Stark Law) 

(42 U.S.C. § 1395nn)

The Stark Law is aimed at punishing those doctors who refer patients to receive specialized medical care from any facility or business that the doctor, or any member of the doctor’s immediate family, has some financial interest in. 

For example, if an general practitioner, after seeing a patient, recommends that they need some type of imaging service, like a CAT scan and refers them to an imaging center.

If the physician refers the patient to a imaging center that the physician’s daughter owns, that referral would be a violation of the Stark law. 

Other statutes that if violated would be considered health care fraud includes the Exclusion Statute (42 U.S.C. § 1320a-7).

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What are the Main Differences and Similarities Between Federal Health Care Fraud Law and New York State Health Care Fraud Law?

There are several differences and similarities between the health care fraud laws of the federal government and the health care fraud law of New York State. 

Below, we discuss an important few of those differences and similarities. 

Investigations

Under federal law, the investigations will be typically be conducted by several government agencies working in conjunction with one another.  

These agencies include: 

Federal Bureau of Investigations (FBI)
Department of Justice (DOJ)
Department of Health and Human Services – Office of Inspector General (HHS-OIG)

The prosecution will fall to the United States Attorney’s Office for the appropriate federal jurisdiction.

For example, if the fraud took place through a medial clinic in Brooklyn then the United States Attorney for the Eastern District of New York would most likely handle the case. 

On the other hand, if the fraud took place through a hospital in Manhattan then the  United States Attorney for the Southern District of New York would most likely handle the case. 

Under New York law, the investigations into allegations would likely be conducted by local law enforcement. 

In New York City this would the New York City Police Department (NYPD). 

The prosecution will be on the District Attorney (DA) from the appropriate office. In New York City the DA’s are split by country. 

So for health care fraud violations that take place in Queens, the Queen’s County DA would be in charge of the prosecution. For  health care fraud violations that take place in Brooklyn, the King’s County DA would be in charge of the prosecution.